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Oregon Department of Environmental Quality <br /> 1. General System Information <br /> The Existing System.Evaluation Report form contains 8 pages:Some of the questions on this <br /> form may not pertain to they system being evaluated;as there are many systems designs. If you.(the <br /> septic system evaluator)are unable to answer any of the questions on this form please indicate,in. <br /> writing,why'this information was not available at thetime the evaluation was completed: <br /> The existing septic system consists of(check all that apply): <br /> ^x lSeAtic Tank I' Cesspool <br /> Dosing Tank 1_ x_}Disposal Trenches/Leach Lines <br /> LiMulti-compartment Tank !Capping Fill <br /> Seepage.Bed c Sand Filter <br /> Li Other(please describe) <br /> Note:Cesspools:may be used.only to Serve existing sewage loads and if failing only be,replaced with <br /> a seepage pit system on lots that are toosmall to accommodate a standard system or other alternative <br /> onsite system. <br /> * There is a permit for the septic system I x l Yes I _i No E __i Unknown <br /> • Permit Numbers) 12-00764 <br /> * Year original septic system installed: 2012 (YYYY) L_ No record of installation date <br /> * Dates of subsequent repairs or alterations: (YYYY) <br /> * All plumbing fixtures are connected to the septic system ! x j Yes I No I J.Unknown <br /> If you answered"No,"or"unknown,"please describe below: <br /> * Additional Comments: <br /> 2. Overall Septic System Status <br /> * Discharge<of"sewage to the ground surface .Yes x 3 Na ;None observedan . <br /> * Discharge of sewage to surface waters Yes { x No i 1None observed. <br /> * Sewage backup into-plumbing fixtures Yes x I No I__ ..Unknown <br /> * Additional Comments: <br /> 3. Septic tank. <br /> In order to fully describe the condition of the tank,the septic tank may need tobe pumped.'Please indicate. <br /> below if theseptic system tank was pumped during the course:.of this evaluation. <br /> * Septic tank was pumped during the course of this evaluation x ?Yes ; I No <br /> * If the septic tank was.NOT pumped during the course of this evaluation,please explain(e.g.. <br /> septic system owner declined tohave the tank pumped etc): <br /> Page 2 of 8 <br />